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   Table of Contents      
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 100-105

A Study on Perception of Stress Among First-Year Medical Undergraduates During COVID-19 Pandemic


1 ESIC Medical College and Hospital, MIA, Alwar, Rajasthan, India
2 Jawaharlal Nehru Medical College, AMU, Aligarh, UP, India
3 ESIC Medical College & Hospital, NH-3, NIT, Faridabad, Haryana, India
4 Diabetes Care Clinic, Aligarh, UP, India

Date of Submission11-Jan-2022
Date of Decision17-Jan-2022
Date of Acceptance04-Apr-2022
Date of Web Publication11-Jul-2022

Correspondence Address:
Praveena Sinha
Senior Resident, Department of Physiology, ESIC Medical College & Hospital, Faridabad, Haryana, India-121001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_3_22

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  Abstract 


Background: Medical students have been reported to suffer from a higher degree of perceived stress compared to the age-matched population doing other courses. Stress caused by the ongoing coronavirus disease (COVID-19) pandemic, lockdown, and the consequent shift of teaching methods to digital format has further compounded the stress associated with pursuing the medical curriculum. Aims and Objectives: Our study aimed to assess perceived stress among first-year MBBS students during COVID-19 induced lockdown using a self-administered Perceived Stress Scale (PSS-10) questionnaire. Materials and Methods: A total of 108 first-year MBBS students in the 18–25 years age group of both sexes were administered a 10-item questionnaire: PSS-10 during 2 months from June-July 2021and depending on their scores of PSS were divided into three groups Group A, B, and C signifying mild, moderate, and severe stress perceived by them, respectively. The continuous variables are presented as mean ± standard deviation and the categorical variables as proportions. Analysis of Variance (ANOVA) was used to compare the data between continuous variables in the three groups. Result: There was a statistically significant difference in the PSS scores between the three groups when a comparison was done (P < 0.05). A larger segment of the first-year medical students undergoing medical curriculum during the COVID-19 pandemic were found to be moderately (63%) to severely (4%) stressed. Conclusion: Our study suggested that the stress induced by the pandemic in addition to the stressors associated with undertaking medical courses creates a highly stressful environment for the medical students predisposing them to significant psychological morbidity.

Keywords: COVID-19 pandemic, perceived stress, Perceived Stress Scale, stressors


How to cite this article:
Khullar S, Das S, Rizvi SA, Sinha P, Abidi SA, Baisla R. A Study on Perception of Stress Among First-Year Medical Undergraduates During COVID-19 Pandemic. MAMC J Med Sci 2022;8:100-5

How to cite this URL:
Khullar S, Das S, Rizvi SA, Sinha P, Abidi SA, Baisla R. A Study on Perception of Stress Among First-Year Medical Undergraduates During COVID-19 Pandemic. MAMC J Med Sci [serial online] 2022 [cited 2022 Oct 6];8:100-5. Available from: https://www.mamcjms.in/text.asp?2022/8/2/100/354399




  Introduction Top


Stress is part and parcel of student life, capable of impacting them in both positive and negative ways. An optimal level of stress, referred to as “favorable stress,” can enhance learning and help to keep an individual motivated, but chronic and intense stress can arouse feelings of fear, uselessness, anger, incompetence, and guilt. If an instance of severe stress is not properly managed, it can cause high levels of anxiety, depression, substance abuse, sleep problems, relationship problems, and suicide.[1]

Medical education promises a well-respected career because of its esteemed place and financial security in the Indian society but is highly demanding on students since it involves tight schedules and a vast curriculum compacted into a short duration of time. Medical students experience a significantly higher stress level compared to the age-matched population.[2] First-year undergraduate students specifically stand on the brink of a major transition in life as they journey from a phase of rote learning to self-directed learning. This sudden transition along with a hectic curriculum and rapid dynamism of the social environment activates a distress cycle in the medical students. While it is well documented that academic stress stands out as a major contributor to distress in medical students, psychosocial factors, environmental stressors, inadequate study leaves, the vastness of the academic curriculum, accommodation away from home, and high parental expectations stand out among other few.[2],[3] Medical undergraduates have been reported to experience a high level of stress with a prevalence between 27% and 73% in various studies conducted in several countries spanning different continents all over the globe.[4]

Traditional medical learning encompasses classroom teaching along with bedside clinical teaching. The coronavirus disease (COVID-19) pandemic, which has thrown the world into lockdowns on and off, is an unprecedented challenge to the implementation and assimilation of medical education. This has caused most of the medical institutions in India to resort to digital platforms for teaching purposes.[5],[6] Majority of the similar studies carried out earlier were predominantly carried out in southern and eastern parts of India. We have attempted to assess the stress levels of medical students in North India using the Perceived Stress Scale-10 (PSS-10), which are far few.

The stress levels on medical students due to the COVID-19 pandemic induced shutting down of medical colleges and the introduction of novel e-learning techniques is an unexplored arena in the field of medical education. These may be considered the novelty of our study.


  Materials and Methods Top


Study design

The study was conducted in the Department of Physiology of a Government Medical College located in the Delhi/NCR region for 2 months between June and July 2021. It was undertaken under the Short Term Studentship scheme of the Indian Council of Medical Research for MBBS students. Institutional Ethical Clearance was sought and obtained following approval of the project from ICMR. All surveys were conducted using the web-based application Google forms.

Study design

Cross-sectional.

Subject selection

The study was performed on 108 first-year MBBS students of both sexes aged between 18 and 25 years. The purpose of the study was explained to all the subjects and written informed consent was obtained from them before the commencement of the study. The consent form and questionnaire were shared with all 125 MBBS students of first year. However, the final number of subjects was 108, considering the following inclusion and exclusion criteria:

Inclusion criteria
  1. Healthy first-year MBBS students of both the sexes aged between 18 and 25 years
  2. Subjects who gave their consent to be a part of the study


Exclusion criteria
  1. History of any chronic medical illness
  2. Physical disability
  3. Neurological disorders
  4. Current psychotropic drug use
  5. History of psychiatric illness
  6. Subjects with a hearing problem


The subjects were divided into three groups based on their PSS scores:

Group A: Mild stress: PSS score – 0 to 13

Group B: Moderate stress: PSS score – 14 to 27

Group C: Severe stress: PSS score – 27 to 40

Perceived Stress Scale questionnaire

The PSS is one of the most widely used psychological tools for measuring the perception of stress. It is a self-administered questionnaire developed by Cohen et al. in the year 1983.[7] The psychometric properties of PSS have been validated extensively and found to be reliable.[1],[7],[8] PSS is interesting and important because it reflects a person’s perception of what is happening in their life as most important and not the event per se. If two individuals are having the same events and experiences in their lives for the past month, the total PSS score puts individuals in the various categories of stress levels depending on their perception of the very same events/experiences. The PSS-10 questionnaire used by us consists of 10 items. The negative elements are intended to assess the lack of control and the negative affective reactions, while the positive element measures the degree of the ability to cope with the existing stressors. Each item is rated on a five-point scale from 0 = “never” to 4 = “very often.” The questionnaire having details of the scale was designed for the students using “Google forms” and the link to the form was sent to them via email for purpose of convenience to be filled from anywhere. Individual scores on the PSS can range from 0 to 40 with higher scores indicating higher perceived stress. The scores of PSS ranging from 0 to 13 indicate low stress, scores ranging from 14 to 26 moderate stress, and scores ranging from 27 to 40 high perceived stress.[7]

Statistical analysis

The collected data were entered in a Microsoft excel sheet and analyzed using Epi Info version 7 software. The continuous variables such as latency and age are presented as mean ± standard deviation and in percentages. The categorical variables are tabulated as proportions and chi-square statistical test was used to test the difference between categorical variables. Analysis of Variance (ANOVA) was used to compare the data between continuous variables in three groups and the student “t test” in the two groups.


  Results Top


The present study evaluated the level of stress in first-year medical students aged between 18 and 25 years as evaluated by PSS-10. We conducted the study using 108 students who were divided into three groups based on their PSS scores.

The age distribution of the subjects can be seen in [Table 1]. The mean age of the subjects was 21 ± 1.23 years.
Table 1 Age distribution of the study participants

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The gender distribution of the subjects is given in [Table 2]. The total number of subjects was 108, out of which 68 (63%) were males and the remaining 40 (37%) were females.
Table 2 Gender distribution of the subjects

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[Table 3] gives the mean PSS scores of the study participants. The overall PSS score was 15.83 ± 5.62. There was a statistically significant difference in the scores when a comparison was done between the three groups (P < 0.05). Scores in Group C (severely stressed) category were significantly higher than those who were having mild and moderate stress.
Table 3 PSS scores of the study participants

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There was no significant difference in the male and female subjects when a comparison was done of the PSS scores [Table 4].
Table 4 Comparison of male and female participants for their PSS scores

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  Discussion Top


The current research was undertaken to study the perception of stress in the first-year medical undergraduate students as assessed by the PSS during the nationwide COVID-19 lockdown. A total of 108 subjects of either sex were included in the study and they were divided into three groups on the basis of their PSS score: Group A: 0 to 13; Group B: 14 to 26; and Group C: 27 to 40. Significant variation was found in the PSS scores of the three groups. Most of our study participants were found to be moderately stressed (63%). Females were found to be more stressed than males; however, this difference was not statistically significant.

If the high levels of unwanted stress are not properly managed in first-year undergraduates, it has the potential to significantly undermine their health and sense of well-being. Chronic stress can have a negative impact on the cognition and comprehension of medical students, suppress and inhibit their learning, and in turn affect their academic performance.[9] Increasing stress levels could lead to anxiety, depression, suicidal thoughts, interpersonal conflicts, sleep disturbances, poor academic and clinical performance, and alcohol and substance abuse.[10]

The genesis of stress in medical students may be multifactorial. In our study, the most important stressor could have been COVID-19 imposed sudden shutdown of conventional teaching methods, lack of communication with teachers, and lack of the academic environment of college. Traditional medical learning encompasses classroom teaching along with bedside clinical teaching. COVID-19 pandemic, which has thrown the world into lockdowns on and off, is an unprecedented challenge to the implementation and assimilation of medical education. All the colleges have been forced to shut down multiple times suspending classroom and clinical bedside teaching. Most of the medical institutions in India have resorted to digital platforms for the purpose of teaching. Although the technology for online education is available in India, its utilization has not been widespread. Their effective utilization poses many challenges, such as less internet penetration in many parts of India, the unfamiliarity of both teachers and students with the usage of digital media, and equipment for online teaching being unaffordable for some students.[5],[6] Further stress is created by the increasing need to undergo specialization courses to train themselves for e-learning. The entire learning procedure has been much delayed due to lockdown leading to uncertainty on academic progression, which is no doubt an apparent and significant stressor to the mental health of our medical students affecting it adversely. Hence, the COVID-19 lockdown causing the shutdown of conventional classes is a predominant source of stress in our student cohort where medical studies are now associated with the adoption of digital e-learning technology.

However, other commonly known stressors during medical education will further compound the stress due to COVID pandemic and may be classified into the following three broad categories:
  1. Academic reasons such as exam tension, diminished duration of first-year MBBS to 1 year with three extensive basic sciences subjects to be covered, frequent ongoing weekly tests leading to burnout, and lack of time for recreation
  2. Family-related reasons such as being pressured by parents to study medicine, keeping up with parent’s ambitions and expectations, and homesickness in hostellers
  3. Psychosocial reasons such as the lack of confidence, inability to handle academic pressures, difficulty in concentrating, inferiority complex, lack of communication skills, language barrier, not getting along well with friends, relationship troubles, feeling of isolation, loneliness, and poor quality of hostel food[11]


A number of studies have been conducted all over the world to study the stress level of medical students over the years. A variety of instruments have been used to study their stress levels. While many studies used self-rated questionnaires, others utilized structured questionnaires such as the General Health Questionnaire, Professional Life Stress proforma, Presumptive Life Stress Questionnaire, Stress Management Questionnaire, Zung Scale for Stress, and PSS.

The study conducted by Bhavani et al. in 2018 on 303 medical students in a medical college located in Mysore with an age group similar to ours, between 18 and 24 years, too concluded that most of the students suffered from moderate stress (74%). According to their study, the vastness of the medical syllabus and lack of proper time management lessons for the students were the prominent reasons for academics being a major stressor for students.[12] The findings of our study are similar to those conducted by John and Naik,[2] Chowdhury et al.,[4] Anuradha et al.,[13] and Rebello et al.,[14] all of which found the medical undergraduate students undergoing moderate to severe degree of pathologic stress. Several other studies also deduced results similar to ours with the academic-related stressor being the major contributor to stress.[2],[3],[4],[12],[13],[14],[15],[16],[17],[18],[19] However, some studies like the one by Kumar et al. conducted among medical students in Mysore, Karnataka, concluded that their students suffered from only mild stress.[20] The differences in the result of our study from them can be attributed to the different lifestyles, cultures, and academic environments of different medical colleges across the country.[2]

Female students in our study showed higher PSS scores compared to male ones, although the difference was not statistically significant. Similar results of the predisposition of female medical students to stress over male students have been reported by a number of authors.[21],[22],[23],[24],[25] This may be due to the fact that women articulate depressive symptoms, even minor ones, more easily, which contributes to a higher stress score.[23] A study conducted in Saudi Arabia was of the opinion that male and female students have separate campuses in their country with the relatively poorer learning environment, lesser educational facilities, and recreation opportunities existing on the female campuses making them more vulnerable to stress.[25] A study conducted in Pakistan showed higher PSS scores in females when compared to males whose plausible reason may be the conservative nature of their society, where women lack the freedom to participate in extracurricular activities owing to the restrictions imposed on them by the society.[26] Another reason for the detection of a higher level of stress amongst female students could be the higher participation of female students in the study as in the one carried out in Kerala.[16] Higher female literacy rates in Kerala compared to the rest of the country leading to more female students qualifying for medical entrance exams could have affected the outcome of this study. The hormonal status of women may help them deal with stress better in comparison to males due to the direct association of stress with autonomic imbalance. Vagal (parasympathetic) tone has been known to have an inhibitory influence on stress while sympathetic activity increases it and estrogen is established as a sympatho-inhibitor and vagotonic hormone. Also, a metabolite of progesterone exerts a sympatho-inhibitory effect on baroreflex responses via a central mechanism.[27] However, the stress in modern-day life can be an important factor overcoming the beneficial influence of the female hormonal milieu on the psychological stability of young females. Our findings are contrary to the study conducted by Shakthivel et al.,[28] where moderate and higher stress was detected more among males (50%) when compared to girls. Similar reports of higher stress levels among male medical students have also been reported by other studies.[4],[13],[29] Higher participation by males in these studies and male hormonal status predisposing them to stress could be the factors influencing. However, some studies have also reported that no gender difference exists with regard to the perception of stress, which is in contradiction to our findings.[29],[30]

Several strategies can be implemented to reduce the stress level of students while undergoing medical undergraduate training. One of them is making the students aware of the early symptoms of anxiety and stress so that they can be empowered to reach out and seek help in times of need. Mental health care services can be made accessible to students such as having a dedicated psychological help clinic on the campus or having alternate means of communication through a helpline or email dedicated to this cause. Peer mentorship programs can help students relate to seniors and share their concerns with them. Informal channels of consultation with psychiatrists and clinical psychologists may be considered, especially for cases where the student is not clear whether the distress requires clinical attention or not and treatment may be met out in the form of psychotherapy and/or medications. Moreover, health promotion and resilience-enhancing measures such as Yoga, psychological counseling, and promotion of recreational activities in medical college may be considered.

Strength and limitations of the study

To the best of our knowledge, this is one of the very few studies aimed to perceive stress in a medical student during the COVID-19 lockdown. Further strengths of our study are its design, the high response rate by medical students, and the single attempt survey; the collection is done on the same time duration.
  • Since our sample size was small, the analyses did not have enough power to control for multiple potential confounders.
  • The project was started during the COVID-19 pandemic, and hence the questionnaire was mailed to the students via email. Some participants did not respond to the mail despite repeated written/verbal reminders.
  • The information from the students about their stress levels was collected on the basis of a self-administered questionnaire; hence, there remains a possibility of information bias. Since the questions of the scale are based on the past experiences of the students in the previous month, memory/recall bias also is a confounding factor.
  • Lack of generalization of the study results to other medical schools in India is another important limitation.


Future research directions
  • Our study was conducted exclusively on first-year MBBS students. Similar studies need to be done to assess the levels of stress in students of other semesters as well over the entire medical course.
  • Studies analyzing the various stressors responsible for the rising stress levels of medical students during the COVID-19 pandemic situation in India and remedial measures to combat them can be taken up in the future, based on the findings of our study.
  • Similar assessment needs to be carried out in other medical colleges to compare and generalize our result findings and to pave way for implementing reforms like online stress management programs for improvement in positive coping skills of medical students to stress during COVID pandemic times.



  Conclusion Top


Our study was conducted on 108 first-year MBBS students aged between 18 and 25 years during the March and April months of 2021 when the country was reeling under the effect of the second wave of the COVID pandemic. The medical students were subjected to the stress of undergoing medical training in online mode apart from coping with the impact of the COVID pandemic on the personal lines of each of them. A larger segment of the first-year medical student participants were found to be moderately (63%) to highly (4%) stressed. However, no significant influence of gender of the subjects was seen on the study outcome.

Acknowledgment

The authors thank the Indian Council for Medical Research which supported the study through its Short Term Studentship program for undergraduate medical students.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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